A method for estimating solid organ donor potential by organ procurement region

Canadian organ donation organizations' donor audit processes: an environmental scan

PURPOSE

Deceased donor audits (DAs) allow organ donation and transplantation systems to measure and analyze missed donation opportunities (MDOs). Missed donation opportunities can harm both patients/families denied the opportunity to donate and patients on transplant waitlists denied access to lifesaving organs. In Canada, there are no national standards for DAs, data analysis, nor accountability processes surrounding MDOs. Understanding DA current practice in each jurisdicton would facilitate developing a national strategy for DAs.

METHOD

All provincial organ donation organizations (ODOs) were invited to participate in an environmental scan (ES) of current DA practices. The two ES phases were an electronic survey followed by semistructured interviews. We collected information about the objectives, frequency, scope, data collection methodology, resources required, definitions/metrics used, and process for reporting outcomes.

RESULTS

All eleven ODOs participated in both phases of the ES (July and October 2019). The primary purposes for conducting DAs were to estimate the following: 1) donor potential (5/11, 45%); 2) system performance at the provincial level (3/11, 27%); and 3) system performance at the hospital level (3/11, 27%). Frequency of DAs varied from weekly to annually, depending on the availability of death reports, urban vs rural setting, and staffing. High variability was observed in DA methodology, donor definitions, and metrics across jurisdictions.

CONCLUSION

There is significant variability across Canadian ODOs in the methodology, definitions, timeliness, data collection, and reporting of DAs. This underscores the need for a national donor audit strategy to reduce preventable harm from MDOs to patients/families at end of life and those on transplant waitlists.

Predicting Expected Organ Donor Numbers in Australian Hospitals Outside of the Donate-Life Network Using the ANZICS Adult Patient Database

Background

The majority of organ donations in Australia occur in the DonateLife Network of hospitals, but limited monitoring at other sites may allow donation opportunities to be missed. Our aim was to estimate expected donor numbers using routinely collected data from the Australian and New Zealand Intensive Care Society Adult Patient Database and determine whether unrecognized potential donors might exist in non-DonateLife hospitals.

Methods

All deaths at 150 Australian intensive care units (ICUs) contributing to the Australian and New Zealand Intensive Care Society Adult Patient Database were analyzed between January 2010 and December 2015. Donor numbers were extracted from the Australian and New Zealand Organ Donor registry. A univariate linear regression model was developed to estimate expected donor numbers in DonateLife hospitals, then applied to non-DonateLife hospitals.

Results

Of 33 614 deaths at 71 DonateLife hospitals, 6835 (20%) met criteria as “ICU deaths potentially suitable to be donors,” and 1992 (6%) were actual donors. There was a consistent relationship between these groups (R² = 0.626, P < 0.001) allowing the development of a prediction model which adequately estimated expected donors. Of 8077 deaths in 79 non-DonateLife ICUs, 452 (6%) met criteria as potentially suitable donors. Applying the prediction model developed in DonateLife hospitals, the estimated expected donors in non-DonateLife hospitals was 130. However, there were only 75 actual donors.

Conclusions

It is possible to estimate the expected number of Australian organ donors using routinely collected registry data. These findings suggest that there may be a small but significant pool of underutilized potential donors in non-DonateLife hospitals. This may provide an opportunity to increase donation rates.

This retrospective analysis of the Australian and New Zealand Intensive Care Society Adult Patient Database data registry suggests that it is possible to estimate the expected number of organ donors and recognizes the existence of a small but significant pool of under-utilised potential donors. Supplemental digital content is available in the text.

Presumed Consent and other Predictors of Cadaveric Organ Donation in Europe

Context

Few studies on presumed consent and environmental predictors of cadaveric organ donation in Europe have been published.

Objective

To determine if a presumed consent policy and other variables can be used to predict the cadaveric organ donation rate per million population.

Design

Secondary analysis of published data.

Setting

Europe.

Participants

The unit of analysis for this study is the individual country.

Main Outcome Measure

Cadaveric organ donation rate per million population.

Results

Original and transformed data were subjected to ordinary least-squares regression. All 4 independent variables were significant predictors of cadaveric donation rate, including (1) having a presumed consent (opting-out) policy in practice, (2) number of transplant centers per million population, (3) percentage of the population enrolled in third-tier education, and (4) percentage of population that is Roman Catholic.

Conclusion

Findings may be useful to academics and professionals responsible for organ procurement. Additional research is necessary for practical application of findings. Generalizing these findings beyond Europe may be problematic because of external validity constraints.

Estimating the Number of Organ Donors in Australian Hospitals--Implications for Monitoring Organ Donation Practices

The Australian DonateLife Audit captures information on all deaths which occur in emergency departments, intensive care units and in those recently discharged from intensive care unit. This information provides the opportunity to estimate the number of donors expected, given present consent rates and contemporary donation practices. This may then allow benchmarking of performance between hospitals and jurisdictions. Our aim was to develop a method to estimate the number of donors using data from the DonateLife Audit on the basis of baseline patient characteristics alone.

Australian audit of intubated deaths in 68 hospitals allowed development of a highly predictive model of organ donation that permits estimation of potential donor numbers.

Estimating the potential of tissue donation in Scotland

The Scottish National Blood Transfusion Service became the preferred provider of tissues in 2000. At that time, the only tissues procured were heart valves and some tendons from multiorgan donors. These sources and the range of tissues were not enough to provide for the clinical needs of Scottish patients. A systematic review was undertaken using the International Classification of Disease codes to assess what the potential pool of tissue donors would be by region, hospital and hospital department. Such data would enable us to focus our limited resources to maximize the yield of tissues to meet clinical demand. The data from this study were validated by a case-note audit in one hospital in Edinburgh. It was shown that the maximum tissue donor potential of approximately 48.5 per million population was in the central belt of Scotland in hospitals with large emergency medicine departments.

Effect of population aging on the international organ donation rates and the effectiveness of the donation process

This study analyzed the effect of population aging on organ donation for transplants in 43 countries and on the effectiveness of the donation process by comparing the results between Spain and the United States. The percentage of the population aged 65 or over accounted for 33% of the difference in the donation rates between the countries and for 91% of the variation in the rates after age adjustment. However, the level of aging of the Spanish (16.5%) and American (12.3%) populations failed to account for the percentages of deceased donors 65 or over (28% vs. 10%), due to the different age-specific donation rates, much higher in Spain above 50 years. These differences lead to a higher effectiveness of the process in the United States (3.1 transplanted organs per donor vs. 2.5 in Spain), though at lower rates of transplant per million population (73 vs. 87). We conclude that older populations have a greater donation potential as donation rates are strongly associated with population aging. It should therefore be mandatory to adjust donation rates for age before making comparisons. Additionally, effectiveness decreases with older donors, so age should be considered when establishing standards relating to organ donation and effectiveness of the process.

Brain death diagnoses and evaluation of the number of potential organ donors in Québec hospitals

PURPOSE

Faced with our inability to respond to the growing number of Quebec patients waiting for organ transplants, we sought to determine the number of potential organ donors (OD) in acute care hospitals.

METHODS

A retrospective chart review of all acute care, in-hospital deaths in Quebec in the year 2000 was undertaken. Hospital record librarians provided statistics and completed questionnaires on each chart after applying exclusion and inclusion criteria.

RESULTS

There were 24,702 acute care in-hospital deaths reported by 83 hospitals participating in the study on a voluntary basis. Analyzing 2,067 files meeting inclusion criteria, we identified 348 potential OD (1.4% of deaths). In hospitals not providing tertiary adult trauma care, the potential donor rate was 0.99% of all deaths. There were 4.5 times more potential donors in tertiary care adult trauma centers. Brain death was formally diagnosed in 268/348 patients, and organ donation discussed as an option with 230/268 families. Consent for donation was given in 70% of cases, although not all these patients proved to be suitable after evaluation. There were 125 actual donors in Quebec in the year 2000 (18 per million population).

CONCLUSIONS

The gap between used and potential donors can be explained by several factors including failure to approach families for organ donation, family refusal, incomplete neurological assessment of patients, and medical unsuitability of some consented donors. There is room for improvement in the identification of potential donors and in the presentation of organ donation as an end of life option to families.

Explaining differences between hospitals in number of organ donors

The shortage of donor organs calls for a careful examination of all improvement options. In this study, 80 Dutch hospitals were compared. They provided 868 donors in a 5-year period, constituting 91% of all donors in that period in The Netherlands. Multilevel regression analysis was used to explain the differences between hospitals. Potential explanatory variables were hospital-specific mortality statistics, donor policy and structural hospital characteristics. Of all donors, 81% came from one quarter of the hospitals, mainly larger hospitals. A strong relationship was found between the number of donors and hospital-specific mortality statistics. Hospitals with a neurosurgery department had additional donors. Seven hospitals systematically underperformed over a period of 5 years. If these hospitals were to increase their donor efficiency to their expected value, it would lead to an increase of 10% in the number of donors. Most donors are found in large hospitals, implying that resources to improve donor-recruitment should be channelled to larger hospitals. This study presents an efficient strategy toward a benchmark for hospitals of their organ donation rates. Some larger hospitals performed less well than others. This suggests that there is still room for improvement. There is no evidence for large undiscovered and unused pools of donor organs.

Quantifying organ donation rates by donation service area

Previous measures of OPO performance based on population counts have been deemed inadequate, and the need for new methods has been widely accepted. This article explains recent developments in OPO performance evaluation methodology, including those developed by the SRTR. As a replacement for the previously established measure of OPO performance--donors per million population--using eligible deaths as a national metric has yielded promising results for understanding variations in donation rates among the donation service areas assigned to each OPO. A major improvement uses "notifiable deaths" as a denominator describing a standardized maximal pool of potential donors. Notifiable deaths are defined as in-hospital deaths among ages 70 years and under, excluding certain diagnosis codes related to infections, cancers, etc. A most proximal denominator for determining donation rates is "eligible deaths," which includes only those deaths meeting the criteria for organ donation upon initial assessment. Neither measure is based on the population of a geographic unit, but on restricted upper limits of deaths that could be potential donors in any one locale (e.g., hospital or OPO). The inherent strengths and weaknesses of metrics such as donors per eligible deaths, donors per notifiable deaths, and number of organs per donor are discussed in detail.

Monitoring organ donor rates: a predictive model based on routinely available data in France applied to the year 2002

Temporal trends in organ donor harvesting rates are subject to variability. It is important to detect variations as early as possible using current data. We developed a predictive model for monitoring harvesting activity using the number of donors harvested monthly between 1996 and 2001. A Poisson model was used to predict the number of donors harvested each month along with their confidence intervals. This model also updates, on a monthly basis, the predicted number of donors for the current year. During 2002, the number of donors observed each month followed the predicted monthly variations, but a significant increase was observed in March and May. These models can be used by transplantation agencies for monitoring purposes and for the evaluation of organ donation programmes.

Estimating the number of potential organ donors in the United States

BACKGROUND

As the need for transplantable organs increases, waiting lists of patients become longer. We studied the size and composition of the national pool of brain-dead organ donors during a three-year period and, on the basis of these data, considered ways to increase the rate of donation.

METHODS

We reviewed hospital medical records of deaths occurring in the intensive care unit from 1997 through 1999 in the service areas of 36 organ-procurement organizations to identify brain-dead potential organ donors. We examined data on characteristics of the potential donors, the processes of referral to organ-procurement organizations and of requesting donations, and the hospitals.

RESULTS

We identified a total of 18,524 brain-dead potential organ donors during the study period. The predicted annual number of brain-dead potential organ donors is between 10,500 and 13,800. The overall consent rate (the number of families agreeing to donate divided by the number of families asked to donate) for 1997 through 1999 was 54 percent, and the overall conversion rate (the number of actual donors divided by the number of potential donors) was 42 percent. Hospitals with 150 or more beds were more likely than smaller hospitals to have potential donors and actual donors (P<0.001); 19 percent of hospitals accounted for 80 percent of all potential donors. Calculations of the number of donors per million persons in the general population did not correlate well with the performance of organ-procurement organizations as measured by the conversion rate.

CONCLUSIONS

Lack of consent to a request for donation was the primary cause of the gap between the number of potential donors and the number of actual donors. Since potential and actual donors are highly concentrated in larger hospitals, resources invested to improve the process of obtaining consent in larger hospitals should maximize the rate of organ recovery. The performance of organ-procurement organizations can be assessed objectively through the comparison of the number of actual donors with the number of potential donors in the given service area.

Presumed consent and other predictors of cadaveric organ donation in Europe

CONTEXT

Few studies on presumed consent and environmental predictors of cadaveric organ donation in Europe have been published.

OBJECTIVE

To determine if a presumed consent policy and other variables can be used to predict the cadaveric organ donation rate per million population.

DESIGN

Secondary analysis of published data.

SETTING

Europe.

PARTICIPANTS

The unit of analysis for this study is the individual country.

MAIN OUTCOME MEASURE

Cadaveric organ donation rate per million population.

RESULTS

Original and transformed data were subjected to ordinary least-squares regression. All 4 independent variables were significant predictors of cadaveric donation rate, including (1) having a presumed consent (opting-out) policy in practice, (2) number of transplant centers per million population, (3) percentage of the population enrolled in third-tier education, and (4) percentage of population that is Roman Catholic.

CONCLUSION

Findings may be useful to academics and professionals responsible for organ procurement. Additional research is necessary for practical application of findings. Generalizing these findings beyond Europe may be problematic because of external validity constraints.

Potential organ-donor supply and efficiency of organ procurement organizations

The authors estimated the supply of organ donors in the U.S. and also according to organ procurement organizations (OPOs). They estimated the number of donors in the U.S. to be 16,796. Estimates of the number of potential donors for each OPO were used to calculate the level of donor efficiency (actual donors as a percent of potential donors). Overall, donor efficiency for OPOs was 35 percent; the majority was between 30- and 40-percent efficient. Although there is room to improve donor efficiency in the U.S., even a substantial improvement will not meet the Nation's demand for organs.

Medicare's end-stage renal disease program: current status and future prospects

The twenty-five years of the end-stage renal disease (ESRD) program have been characterized by remarkable clinical achievements, which have prolonged and improved the quality of life for thousands of patients. As the program enters the next millennium, it faces considerable challenges: As the number and acuity of patients increase, the availability of trained nephrologists will decrease, and total costs will continue to rise. Policymakers will need to work closely with the renal professional and patient communities to develop creative approaches to delivering and financing ESRD care that is of the highest quality, yet is affordable.